How Might Healthcare Organizations Engage End-Users to Mitigate Risks to Patient Safety?

By Larry Ozeran MD, President, Clinical Informatics Inc.

HIMSS core objective as an organization is to improve healthcare quality and patient safety through the best use of IT and management systems. As hospitals and providers work to implement electronic health records and other IT and management systems, HIMSS is launching a blog series on health IT and patient safety to help providers and hospitals identify potential risks to patient safety that have resulted from problems with EHR implementations and mitigate those risks through proactive measures.

If you work in an IT department of a hospital, medical group, pharmacy, or other clinical environment, you also risk patient safety when you ignore your users. What reasonable steps can you take to minimize organizational processes that put patients at risk?

Ask yourself key questions:

• Who are my stakeholders? Everyone thinks of clinical providers, but what about the staff responsible for cleaning and packaging surgical instruments or other members of the IT team?

• Do our systems support stakeholder workflow? When you select new systems or upgrade existing ones, do you get input from users on how they expect to use the system in day-to-day operation? Do you ensure that you get broad input by promoting bidirectional communication between stakeholders and the representatives that you may have on project teams? Do you require vendors to demo their software with scripts provided by your stakeholders? Do you maintain ongoing communication about workflow throughout the selection and implementation process?

• What’s not working? How do you know what is not working in your organization? Do you wait for disasters to arise or do you actively seek input? Have you considered that the earlier you identify an IT problem, the smaller the problem tends to be and the easier, less costly, and more quickly it tends to be managed?

• How should I prioritize? Healthcare is highly regulated and costs always seem to rise. Payments seem to be stagnant or dropping. Narrow, and sometimes negative, financial margins in healthcare tend to squeeze IT departments to the point where you simply can’t do everything as soon as you would like. You don’t have the people or resources.

So, what gets done first?

Much depends upon your organizational mission and your leadership. When both are consistent with providing best care for patients, look first at those projects that will reduce death or complications. These would include systems where alerts are triggered inappropriately. These would also include medication reconciliation projects that don’t reflect clinical reality. The way your IT solutions blend with existing workflows, or don’t, will have a key impact on their success, and this will ultimately impact how safe your environment is for your patients.

Let us imagine that you manage a small IT department in a 200-bed hospital. Your mission is “to provide optimal care to the people of our community.” Your leadership manages a 3% profit margin and IT receives 6% of the annual hospital budget. You have modeled your organization to be “failure-ready.” You accept that everyone makes mistakes sometimes, and from the CEO to the lowest paid worker, everyone knows that they can bring an issue forward without fear of being disciplined, just because they found a problem.

In this environment, small problems get raised early, and you have just learned that the ED admitting staff are having an issue with the medication reconciliation software. For some reason, when they add a medication to the patient’s list for review by a clinical provider, if it is in the same class as another drug the patient is already listed as taking, the existing medication disappears. Because this could result in patient harm, this issue is given a level 2 (out of 5) priority when added to the trouble ticket queue. Level 2 issues are investigated (though not necessarily resolved) within 24 hours.

When IT staff investigate, they find that this can occur when a configuration flag is set a certain way. That setting was changed about 10 days prior, strikingly close to when the staff first noticed the changes. Because the flag was changed for convenience issues, the flag was reset to the default, resolving the reconciliation problem. The vendor was subsequently contacted to determine if the convenience issue could be managed in another way.

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One Response to How Might Healthcare Organizations Engage End-Users to Mitigate Risks to Patient Safety?

  1. Good first step, Now we need to have a substantive discussion on how the patient is integrated into the system, i.e., EHR, CPOE, DIRECT, 360X Closed Loop Referral, HIE, etc. We need to promote trust through our adherence to medical ethics, e.g., autonomy, confidentiality, informed consent, etc.. Hence, it is important that HIT capability exist at the point of care that encourages a dialogue between caregiver and patient as to the extent that PHI affects their safety, and how use, modification, loss, or misuse could adversely affect their care and identify.

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